Prevalence and Severity of Alcohol and Cannabis Use Across the Urban- Rural Continuum in the Michigan National Guard Lara N. Coughlin, PhD;1 Maureen A. Walton, MPH, PhD;1,3 Richard McCormick, PhD;4 & Frederic C. Blow, PhD1,2 1 Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan 2 VA Center for Clinical Management Research (CCMR), Department of Veteran Affairs Healthcare System, Ann Arbor, Michigan 3 Injury Prevention Center, University of Michigan, Ann Arbor, Michigan 4 Center for Healthcare Research and Policy, Case Western Reserve University/Metrohealth, Cleveland, Ohio Disclosures: The authors have no conflicts of interest to disclose. Funding: Support for this study was provided through NIAAA R01 AA023122. Dr. Coughlin’s time was funded through NIAAA T32 AA007477. Acknowledgments: We would like to thank the Michigan National Guard service members for their participation in this study. For further information, contact: Lara Coughlin, PhD, 2800 Plymouth Rd, Ann Arbor, MI 48109; Email: [email protected] Running Head: Rural and Urban Alcohol and Cannabis Use This is the author manuscript accepted for publication and has undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/jrh.12412. This article is protected by copyright. All rights reserved. Abstract Purpose: The National Guard provides critical support both domestically and abroad with soldiers dispersed throughout America and spanning the urban-rural continuum. To determine if location-specific interventions may be needed, we compared the prevalence and severity of cannabis and alcohol use among National Guard members across localities. Methods: Michigan National Guard members were enrolled (N=2746) during drill weekends as part of a larger randomized behavioral trial. Cannabis (ASSIST; prevalence=5%) and alcohol use (AUDIT; prevalence=82%) were compared using hurdle regression models across locality status after adjusting for covariates. Findings: Prevalence of cannabis and alcohol use was predicted by locality (AOR=0.913, 95% CI: 0.838-0.986, P = .029; AOR=0.963, 95% CI: 0.929-0.998, P = .038, respectively), with more use in urban localities. Neither severity of cannabis nor alcohol use was predicted by locality status. Conclusions: Prevalence of cannabis and alcohol use in the National Guard is differentially elevated across localities with higher prevalence in more central, densely populated areas. Findings may inform future work considering accessibility and utilization of prevention and treatment services for Guard members across the urban-rural continuum. Key Words: alcohol, cannabis, National Guard, rural, urban This article is protected by copyright. All rights reserved. Reserve Component members of the US Armed Forces, especially the Army National Guard, have played an increasingly important role in recent wars. Approximately one-third of service members deployed overseas have come from the National Guard and Reserves,1,2 and future war planning anticipates heavy use of Reserve Components. An increased reliance on the National Guard requires that their resilience be maintained at a level comparable to active duty forces. This is challenging since they must cope with both their civilian and part-time military roles. Compared to Active Component service members, National Guard soldiers experience a disproportionate burden of mental health and substance use problems, especially following deployment.3,4 Previous national surveys have shown higher rates of alcohol misuse among military personnel than their civilian counterparts.5,6 Overall, estimates of alcohol misuse among Reserve Component service members are slightly lower than Active Component members (16.7% and 20.0%, respectively); however, estimated rates in the Army National Guard (21.1%) are similar to those of Active Component service members.7-10 Prior reports on the use and misuse of cannabis among service members is limited, and rates may be underestimated due to reluctance to admit use which is prohibited and would affect military status and advancement. The most recent Department of Defense (DoD) Survey of Health Related Behaviors reported that 0.6% of active duty respondents used cannabis in the past year, compared to an estimated 8.7% of the civilian adult population; however, the survey had very low response rates.6 Reserve Component members face greater challenges to receiving mental health services, including services for substance use. In contrast to full-time soldiers who reside on base at military stations, National Guard members live throughout their home states, dispersed across the urban-rural continuum. Many National Guard soldiers live in remote areas with health care provider shortages. Prior work points to the decentralized nature of the This article is protected by copyright. All rights reserved. National Guard as increasing their burden to receive services, often leading these soldiers to seek out civilian providers or travel long distances to military or veterans’ health care facilities.11,12 However, the impact of the dispersed residence of National Guard soldiers on alcohol and cannabis use is largely unknown. To the best of our knowledge, no studies report the dispersion of alcohol and cannabis use across urban-rural localities among National Guard members. Assessing the distribution of alcohol and cannabis use among these soldiers may impact policy to reduce barriers and improve access to services. In order to better characterize, meet treatment needs, and provide support to National Guard service members, we consider alcohol and cannabis use in Michigan National Guard members including the intersection with mental health symptoms (depression, anxiety, and PTSD), service (length of service, deployments, rank), and demographic characteristics across localities. Methods Michigan National Guard members were enrolled (N=2746) during drill weekends as part of a larger trial (ClinicalTrials.gov ID: NCT02181283), which was approved by the University of Michigan IRBMED. Procedure Forty-one National Guard units in Michigan were randomly selected from among all units to assure that the sample broadly represented the specialties and geographical locations of all Guard members. Soldiers in attendance at drill weekends from April 2015 to June 2017 were offered the opportunity to participate in an ongoing randomized controlled trial (RCT). Over 26% of the total Michigan Guard membership completed the initial assessment. Soldiers were This article is protected by copyright. All rights reserved. approached in person by research assistants, those interested in participating provided written informed consent, and they completed a self-administered baseline health survey. Participants were compensated $20 for completion of the assessment measures. Measures The primary independent variable of interest, locality status, was based on the home ZIP Code of the National Guard member at the time of participation. Locality status was determined by linking the participant ZIP Code to its Rural-Urban Commuting Area (RUCA) zone13,14 based on the 2010 decennial census and the 2006-10 American Community Survey. Using ZIP Codes to determine rural-urban status provides a finer geographic unit than other county-based categorization systems such as the Office of Management and Budget’s Metro, Non-Metro taxonomy. For the purposes of the current study, RUCA codes were used to define locality status of National Guard service members across the urban-rural continuum, which ranges from 1 to 10.3, where higher values indicate more rural residence. While this variable was used as a continuous variable, values can be interpreted as fitting into the following categories: (1) urban (RUCA = 1-3, area population size ≥50,000), (2) rural (RUCA = 4-6, area population size 10,000-49,999), and (3) extremely rural (RUCA = 7-10.3, area population size ≤9,999). The primary outcome measures of alcohol and cannabis use were assessed using the Alcohol Use Disorder Identification Test (AUDIT) and Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), respectively. The AUDIT, used to assess presence and severity of alcohol use, is a 10-item questionnaire that includes domains on alcohol consumption, drinking behaviors, and alcohol-related problems. Total scores range from 0 to 40 where higher scores indicate greater alcohol use severity.15 The ASSIST, used to assess cannabis use and severity of use, is an 8-item questionnaire that provides a risk score ranging This article is protected by copyright. All rights reserved. from 0 to 44 where higher scores indicate greater severity.16 Outcome measures were missing in 4 cases for the AUDIT and 6 cases for the ASSIST. These individuals were excluded from the analyses. Sample characteristics variables were collected and considered as covariates in the analysis. These included demographic characteristics (age, sex, income, and employment status), mental health questionnaires (Generalized Anxiety Disorder 7 (GAD-7)),17 the Patient Health Questionnaire (PHQ-9),18 the PTSD Checklist for DSM-5 (PCL-5),19 and service history characteristics (years of service in the National Guard, number of prior out-of-country deployments, and current rank in the National Guard). Statistical Analysis The 10 demographic, mental health, and National Guard characteristics reported